Please rate your child's stress levels on a scale of 1-10 (10=high)

WHAT CHANGES, IF ANY, IN YOUR CHILD'S HEALTH OR BEHAVIOR WOULD YOU LIKE ACCOMPLISHED?

Child's Health History

Please check each of the diseases or conditions that the child now or has had in the past. While they may seem �unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.�

PLEASE CHECK ANY AND ALL THAT APPLY:

ANXIETY

ASTHMA

BACK PAIN/STIFFNESS

CONSTIPATION

DIARRHEA

DEPRESSION

DIFFICULTY/PAINFUL/IRREGULAR PERIODS

HEADACHES

HIPS, KNEES, ANKLES

HYPERACTIVITY

LEARNING DISORDERS

NECK STIFFNESS/PAIN

SHOULDERS/ELBOW, WRIST PAIN

STREE

URINARY INFECTIONS

Nutrition

DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD'S DIET?

YES

NO

IF YES, EXPLAIN CONCERNS:

DOES YOUR CHILD HAVE FOOD ALLERGIES?

YES

NO

LIST ALLERGIES

DOES YOUR CHILD HAVE PERSISTENT OR INTERMITTENTLY OCCURRING SKIN RASHES?

YES

NO

IF YES, PLEASE EXPLAIN:

DOES YOUR CHILD TAKE VITAMIN SUPPLEMENTS?

YES

NO

IF YES, LIST VITAMIN SUPPLEMENTS:

DOES YOUR CHILD ELIMINATE STOOLS EACH DAY?

YES

NO

IF YES, PLEASE EXPLAIN.

WHAT DOES YOUR CHILD USUALLY EAT FOR BREAKFAST?

WHAT DOES YOUR CHILD USUALLY EAT FOR LUNCH?

WHAT DOES YOUR CHILD USUALLY EAT FOR DINNER?

WHAT DOES YOUR CHILD USUALLY EAT FOR SNACKS?

HOW MUCH COW'S MILK DOES YOUR CHILD DRINK EACH DAY?

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Notice of Privacy Policy

Protecting the privacy of your personal health information is important to us. Disclosure of your protected healthinformation without authorization is strictly limited to defined situations that include emergency care, quality assuranceactivities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment,payment or practice operations will be made only after obtaining your consent. � �- You may request restrictions on your disclosures. � �- You may inspect and receive copies of your records within 30 days with a request. � �- You may request to view changes to your records. � �- In the future, we may contact you for appointment reminders, announcements and to inform you about our practiceand its staff.I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights toprivacy regarding my protected health information. I understand that this information can and will be used to:� �- Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in thattreatment directly or indirectly. � �- Obtain payment from third party payers.� �- Conduct normal healthcare operations such as quality assessments and physician’s certifications.I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I alsounderstand that I can request, in writing, that you restrict how my personal information is used and or disclosed.

BY CHECKING THIS YOU AGREE THAT YOU HAVE READ AND UNDERSTAND ACTIVE FAMILY CHIROPRACTIC'S PRIVACY POLICY

Authorization for Care of a Minor

It is understood and agreed that the payments to the doctor for x -rays is for examination of x-rays only. The x-ray films will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient in this office. I understand that all services are to be paid in full at the time of service, unless other arrangements have been made and agreed in writi ng. I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer chiropractic care, to work with my condition through the use of adjustments and procedures the doctor deems appropriate. I c learly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for paymen t. I agree that I am responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre -existing medically diagnosed conditions nor for any medical diagnosis. I also understand if I suspend or terminate my care for any reason, any fees for professional services rendered me will become immediately due and payable. I hereby authorize assignment of my insurance rig htsand benefits (if applicable) directly to the provider for services rendered.I authorize the use of this signature to allow the insurance companies to pay Active Family Chiropractic directly any amounts payable as my assignment of benefits. I authorize the use of this signature on any insurance submissions.

I authorize the doctor in this chiropractic office to administer chiropractic care to work my condition through adjustments and procedures the Doctor deems appropriate.